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A gastroenterologist’s view of GERD and its pre-operative workup. George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School of Medicine M.I.S.S. 2.21.2012. Disclosures: None. Outline. What can happen How do we find out What can we do about it.
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A gastroenterologist’s view of GERD and its pre-operative workup George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University School of Medicine M.I.S.S. 2.21.2012 Disclosures: None
Outline • What can happen • How do we find out • What can we do about it
= Heartburn/regurgitation - Erosive reflux disease (ERD): Erosions in the distal esophagus - Non-erosive reflux disease (NERD): Normal esophagus and abnormal pH - Barrett’s esophagus: Endoscopic and histologic evidence of intestinal metaplasia/dysplasia
Not all GERD is the same… Peptic stricture • NERD (most common) • Erosive esophagitis (LA B, C and D) • +/- Hiatal hernia • Refractory GERD • Consequences of repair • Peptic stricture • Barrett's metaplasia • Extra-esophageal manifestations • Asthma • Laryngitis • Cough Hiatal hernia
PPI therapy in GERD • The most effective medical therapy available • 90%+ healing rates • 70%+ symptom control rates • Symptoms may continue despite therapy • Relapses may still occur despite maintenance therapy • Subject to drug-drug interactions, long-term side effects and poor adherence
Understand Prevent Manage
PPI may lose efficacy over time! Total percentage acid exposure time at baseline, at the time of normalization, and at 2-year follow-up. Frazzoni M, Dig LivDis 2007
Long term PPI safety • Pneumonia • C.difficile infection • Other enteric infections • Hypergastrinemia • Atrophic gastritis • Vitamin B12 malabsorption • Hip fractures • Drug interactions
GERD in primary care • Patients with heartburn, regurgitation, or chest pain, are typically treated initially with proton pump inhibitors (PPI). • 3 possible outcomes: • Complete response (no symptoms) • Partial response (breakthrough symptoms) • No response (no change in symptoms)
Refractory GERD Clinically significant impairment of health-related well-being (GERD-HRQoL) due to episodes of gastro-esophageal reflux while on PPI therapy “GERD” symptoms may not always reflect the acidity of the refluxate but may be due to: refluxate volume, esophageal distensibility and sensitivity to acid
Achalasia & dysmotility: Defined manometrically • EoE: > 25 eosinophils / hpf • RD (Reflux-like dyspepsia): Normal endoscopy, biopsies and pH monitoring • Gastroparesis: Normal endoscopy, abnormal GES
Esophageal biopsy Eosinophilic esophagitis Barrett’s esophagus
Esophageal Motility • Non-invasive & quasi-physiologic • Measures effectiveness of peristalsis and LES pressure/relaxation • Essential in defining esophageal dysmotility (achalasia, spasm, etc)
HRM depicts esophageal pressure activity from the pharynx to the stomach Fox, M R et al. Gut 2008;57:405-4
24-hr ambulatory pH monitoring • Non-invasive & physiologic • Quantifies acid reflux (off/on Rx) • Correlates symptoms to acid reflux • Sensitivity and specificity > 90% • Indispensable for atypical & refractory cases
“Abnormal” intra-esophageal pH profile on PPI 56 yo man with persistent heartburn while on PPI 24-hr pH study on lansoprazole (30 mg bid) DeMeester score (on therapy): 17.3 % time intra-gastric pH < 4.0: 57.4 ie pH ig pH On high-dose PPI, this patient has achieved an inadequate intra-gastric pH control, resulting in persistent symptomatic GERD
“Normalized” intra-esophageal & intra-gastric pH profile 62 yo man with belching/regurgitation but no heartburn while on PPI 24-hr pH study on rabeprazole 40mg bid. DeMeester score (on therapy): 12.9 % time ig pH<4.0: 27.4
Disease prevalence in PPI-refractory GERD % 270 patients (143 men and 127 women), aged 16-89 years Triadafilopoulos G et al. Gastroenterology 2010
Acid reflux frequently overlaps % Triadafilopoulos G et al. Gastroenterology 2010
Reasons to consider endoscopic therapies for GERD Fundic polyps Refractory GERD Persistent heartburn despite escalatingPPIs Residual regurgitation without heartburn on PPIs PPI intolerance (2% of users) Desire to stop drug therapy (concerns about long-term effects) Concerns about LARS side effects (i.e. dysphagia, gas bloat) Symptomatic GERD after fundoplication Triadafilopoulos, G. Am. J. Med. 115(3A): 192S-200S, 2003.
Stretta Catheter Radiofrequency Rx Enhances LESP Reduces tLESRs Module
Transoralincisionlessfundoplication (TIF) Pre TIF Post TIF Full thickness tissue plications are used to reconstruct & augment the ARB Serosa-to-serosa fixation at 2wks Fasteners Serosa-to-serosa fixation
Who are not good candidates for EndoRx? • Patients with refractory GERD who have a large, fixed, hiatal hernia (> 3 cm long) and foreshortened esophagus Laparoscopic Nissenfundoplication
Who are not good candidates for either endoscopic or surgical therapy? • Patients with “functional” heartburn • Patients with 0 % response to PPIs • “Les malades du petit papier” • Negative pH studies + no symptom correlation with acid events Bravo pH monitoring
Conclusions • Reflux symptoms may or may not reflect GERD • PPI therapy is widely used and quite effective in ~80% of cases • Structural and functional evaluation of the esophagus are essential in refractory cases • Emerging role of endoscopic and newer surgical therapies • Multidisciplinary approach is essential to successful outcomes